Fort Worth women missed breast cancer screenings amid COVID. Here’s why that’s worrisome

Fort Worth women missed breast cancer screenings in 2020, and it’s not yet clear whether that dip in preventive services has rebounded in 2021, according to local providers and screening numbers.

The local trend mirrors a nationwide decline that showed a steep drop in screening mammograms in April and May of 2020, during the beginning of the COVID-19 pandemic in the U.S.

“We definitely saw a decrease in the number of screening and diagnostic mammograms when the pandemic first hit,” Dr. Radha Iyengar, breast surgical oncologist with the Texas Health Physicians Group.

In September 2019 and January 2020, Texas Health Resources averaged 682 mammograms per month at its Kupferle Breast Center in Fort Worth and across its mobile health program. A year later, in September 2020 and January 2021, the average had dropped to 456 mammograms per month.

Physicians are worried that the decline in mammograms could mean that breast cancer will be diagnosed later than it would have been had women had continued access to care throughout the pandemic. The later a breast cancer diagnosis is made, Iyengar said, the harder it is to treat.

Iyengar said she’s already seen a small uptick in patients she is treating with later stages of breast cancer. The most worrisome delays she has observed are in patients who postponed getting a diagnostic mammogram, which is the next level of test after a screening mammogram has detected something abnormal.

“The big things are delaying the diagnostic imaging and noticing alarms and then just sort of saying, ‘I’m not going to come in and get it checked out, it’s probably nothing,’” Iyengar said. “They don’t want to get COVID and then just sort of delaying, delaying, delaying, and then ending up having a bigger problem.”

“If we are able to sort of make up in the next few months that people have missed, and hopefully we won’t have a big, huge, you know, rise in the number of later stage cases, but I think only time will tell,” she said.

More cancer deaths predicted

The outcome of these delays isn’t definite, but some experts have forecast a grim future. In June 2020, the director of the National Cancer Institute cited a model that predicted 10,000 excess deaths from colorectal and breast cancers because of delays in screening and treatment.

Breast cancer is the most common type of cancer for women in the U.S., aside from skin cancer, according to the American Cancer Society. In Texas, breast cancer is also the most common cancer among women, and it is the second leading cause of cancer deaths, according to the state health department.

Dr. Nora Becker, an assistant professor of general medicine at the University of Michigan, published a study in July that looked at a more complete set of data than most other research on how the pandemic affected preventive care. Becker analyzed insurance claims to a commercial health plan in Michigan from 2019 and into early 2021.

The numbers were unambiguous: Breast cancer screenings “dropped almost basically to zero” in June of 2020, Becker said, before rebounding back to baseline levels later in the calendar year.

“But what that meant for the entire calendar year of 2020 was that a lot fewer women ultimately still got screened,” Becker said.

And although screenings eventually returned to pre-pandemic levels, they did not rebound to a level that could make up for the screenings that were missed in the first months of the pandemic.

Becker’s research is geographically limited, as it only analyzed the claims of one commercial insurance plan in Michigan. The state experienced its COVID-19 peaks at different times than Texas.

Questions about the uninsured

What’s also unclear is how the pandemic affected screenings for poor women, including women without health insurance or who have public health insurance such as Medicaid. Becker said there was no data to conclusively understand the situation among uninsured women, but her theory was not optimistic.

“If I was going to take a guess ... this is a commercially insured population and it’s probably the best case scenario,” Becker said. “These are people with good commercial insurance and good access to care. So if I was going to take a guess, among the uninsured, things are probably much worse.”

Texas has the nation’s highest rate of uninsured residents in the nation. Almost one in four nonelderly Texas women did not have health insurance in 2019, according to the Kaiser Family Foundation.

Also unknown is whether the dip in screenings could worsen the existing disparities in breast cancer survival rates. Breast cancer mortality rates for Black Texas women are “significantly higher” than in any other race or ethnicity group, according to the Department of State Health Services.

Rosemary Galdiano is the director of Texas Health’s mobile health program, which provides mammograms and other preventive services primarily for women who don’t have health insurance.

“We are really trying to target women that have difficulty or have barriers to accessing these types of preventive health services that are so vital,” Galdiano said.

Typically, a mammogram must be ordered by a doctor, meaning that people without insurance and a personal doctor might have a harder time getting a screening mammogram ordered. The mobile health program allows women to make an appointment or just walk in to the mobile clinic. If they meet the guidelines and are eligible for a mammogram, they can get one immediately, Galdiano said.

Declines in other screenings

In addition to drops in breast cancer screenings, declines in other preventive services have been observed as well. Becker’s research saw drops in such things as HPV and pap tests, which screen for cervical cancer, screenings for sexually transmitted infections, and the insertion of long-acting birth control methods.

It’s not immediately clear if the delays in breast cancer screenings, as well as other types of cancer screenings like HPV and pap tests and colonoscopies, will cause a long term, nationwide or statewide spike in delayed cancer diagnoses.

Becker, who is also a primary care physician, said the screening rates in 2021 would be key to determining whether the U.S. would see an increase in delayed breast cancer diagnoses.

“What happens in 2021 really matters,” Becker said. “The impact of getting your mammograms six months or a year later, maybe isn’t that great. But if you don’t get it for five years, that is potentially much more serious.”

How to schedule a mammogram

If you don’t have health insurance, there are several options for finding a free or low-cost mammogram:

• Screening mammograms and well-female exams are available for free through the Texas Health Resources’ mobile health program if you don’t have insurance and make less than 200% of the federal poverty guidelines, or less than $25,520 for a household of one person. Call 1-855-318-7696 to schedule an appointment.

• The Moncrief Cancer Institute provides free screenings to uninsured and under-insured women in North and Central Texas. Call 800-405-7739 to request an appointment.

• If you do not have health insurance and make at or below 200% of the federal poverty level, you may be eligible for the Breast and Cervical Cancer Services program, which provides free screening to women who qualify and free treatment if those screenings result in a cancer diagnosis. Call 211 for more information.

Know another resource? Email cmccarthy@star-telegram.com and we’ll update this list.

Who should get a mammogram?

Women should get a screening mammogram every year or every two years depending on their age. Recommendations for when regular screening should begin vary. The American Society of Breast Surgeons recommends that women with an average risk of breast cancer should begin yearly screenings starting at age 40. The U.S. Preventive Services Task Force recommends annual or biennial screenings start at age 50. Your doctor can help you decide when you should start screening mammograms based on your family history.

Most screening guidelines are developed for cisgender women. Transgender patients should talk to their doctor to help determine whether and how often they need mammograms.